Prospective risk assessment for hepatocellular carcinoma development in patients with chronic hepatitis C by transient elastography.

UNLABELLED: Liver stiffness, noninvasively measured by transient elastography, correlates well with liver fibrosis stage. The aim of this prospective study was to evaluate the liver stiffness measurement (LSM) as a predictor of hepatocellular carcinoma (HCC) development among patients with chronic hepatitis C. Between December 2004 and June 2005, a total of 984 HCV-RNA positive patients, without HCC or a past history of it, visited the University of Tokyo Hospital. LSM was performed successfully in 866 patients, who gave informed consent. During the follow-up period (mean, 3.0 years), HCC developed in 77 patients (2.9% per 1 person-year). The cumulative incidence rates of HCC at 1, 2, and 3 years were 2.4%, 6.0%, and 8.9%, respectively. Adjusting for other significant factors for HCC development, patients with higher LSM were revealed to be at a significantly higher risk, with a hazard ratio, as compared to LSM < or =10 kPa, of 16.7 (95% confidence interval [CI], 3.71-75.2; P < 0.001) when LSM 10.1-15 kPa, 20.9 (95% CI, 4.43-98.8; P < 0.001) when LSM 15.1-20 kPa, 25.6 (95%CI, 5.21-126.1; P < 0.001) when LSM 20.1-25 kPa, and 45.5 (95% CI, 9.75-212.3; P < 0.001) when LSM >25 kPa. CONCLUSIONS: This prospective study has shown the association between LSM and the risk of HCC development in patients with hepatitis C. The utility of LSM is not limited to a surrogate for liver biopsy but can be applied as an indicator of the wide range of the risk of HCC development.

Risk assessment of hepatocellular carcinoma in chronic hepatitis C patients by transient elastography.

OBJECTIVE: The degree of liver fibrosis is the strongest indicator of risk for hepatocellular carcinoma (HCC) development. Recently developed transient elastography (Fibroscan, Echosens, France) noninvasively measures liver stiffness, and the correlation between the stiffness and liver fibrosis stage has been validated. In this cross-sectional study, we investigated the relationship between liver stiffness and HCC presence. METHODS: Liver stiffness was measured in chronic hepatitis C patients (85 with HCC and 180 without) by transient elastography. Multivariate logistic regression was applied to assess the association with HCC presence. We computed the receiver operating characteristics (ROC) curves concerning the prediction of HCC presence and compared the areas under ROC curve (AUROC). We also calculated stratum-specific likelihood ratios (SSLR). RESULTS: Multivariate analysis showed that HCC presence was significantly associated with liver stiffness (P<0.0001) along with age, male, and alpha-fetoprotein concentration. AUROC was 0.805, 0.741, 0.714, 0.673, 0.670, and 0.654 for liver stiffness, alpha-fetoprotein, albumin, prothrombin activity, AST-platelet ratio index, and platelet count, respectively. Other parameters showed smaller AUROC. SSLR for HCC presence by liver stiffness was 0.22 (95% confidence interval: 0.11-0.42) in <10 kPa, 0.73 (0.39 to 1.39) in 10.1 to 15 kPa, 1.30 (0.80 to 2.12) in 15.1 to 25 kPa, and 5.0 (2.96 to 8.47) in >25 kPa. CONCLUSIONS: Liver stiffness measured by transient elastography is useful in demarcating chronic hepatitis C patients at a high risk for HCC, who require frequent check-up by imaging examinations.

Intraductal US in the assessment of tumor involvement to the orifice of the cystic duct by malignant biliary obstruction.

BACKGROUND: Tumor involvement to the orifice of the cystic duct (OCD) is a risk factor for cholecystitis after metallic stent (MS) placement. OBJECTIVE: ERCP and intraductal US (IDUS) were used to assess tumor involvement to the OCD. DESIGN: A prospective consecutive study. SETTING: The University of Tokyo Hospital, Japan. PATIENTS AND INTERVENTIONS: Between January 2003 and May 2007, 34 patients with resectable malignant biliary obstruction underwent an ERCP and an IDUS before preoperative biliary drainage. MAIN OUTCOME MEASUREMENTS: ERCP and IDUS findings were confirmed via a histopathologic analysis of surgical specimens. RESULTS: An ERCP showed that the cystic duct was opacified in 22 of 34 patients (64.7%). Eight patients were diagnosed with OCD tumor involvement. In the remaining 12 patients, tumor involvement was impossible to evaluate via an ERCP. An IDUS identified tumor involvement to the OCD in all 34 patients. Tumor involvement to the OCD was diagnosed in 12 patients, including 4 patients with previously negative results during an ERCP. Tumor involvement was confirmed by histopathology of surgical specimens. The sensitivity and specificity of detection were 66.7% (8/12) and 63.6% (14/22), respectively, via ERCP, and 100% (12/12) and 100% (22/22), respectively, via IDUS. LIMITATION: The small sample size. CONCLUSIONS: IDUS, in addition to ERCP, provides an accurate evaluation of tumor involvement to the OCD in patients with malignant biliary obstruction.

Assessment of the risk factors for colonic diverticular hemorrhage.

PURPOSE: Colonic diverticulosis, although usually asymptomatic, sometimes causes diverticular hemorrhage. Studies about risk factors, other than nonsteroidal anti-inflammatory drugs, for colonic diverticular hemorrhage are limited. We conducted the present study to elucidate their significance as a risk factor. METHODS: Colonic diverticulosis was found in 1,753 patients and diverticular hemorrhage in 44 patients among 9,499 total colonoscopy examinees at the authors' institutions between September 1995 and December 2005. After reviewing their clinical features, we chose two controls for each case with diverticular hemorrhage matched for age, gender, and the location of diverticulosis. We evaluated the effects of comorbidities (hypertension, hyperlipidemia, diabetes mellitus, cerebrovascular disease, ischemic heart disease), habits (alcohol, smoking), and medications, including nonsteroidal anti-inflammatory drugs, by using conditional logistic regression analysis. RESULTS: There were no significant differences between patients with diverticular hemorrhage and those with nonbleeding diverticulosis regarding age (67 +/- 13 vs. 64 +/- 11 years) or gender ratio (male/female ratio: 36/8 vs. 1,237/472). As for location, the proportion of bilateral diverticulosis was larger among patients with hemorrhage (43 vs. 22 percent). In the case-control study, nonsteroidal anti-inflammatory drugs (odds ratio, 15.6; 95 percent confidence interval, 1.1-214; P = 0.04), hypertension (odds ratio, 6.6; 95 percent confidence interval, 2.1-20.5; P = 0.0011), and aspirin and/or other anticoagulant (odds ratio, 3; 95 percent confidence interval, 1.04-8.6; P = 0.042) were shown to be significant risk factors by multivariate analysis. CONCLUSIONS: Hypertension, nonsteroidal anti-inflammatory drugs, and anticoagulants, including aspirin, are independent risk factors for colonic diverticular hemorrhage.

Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors.

BACKGROUND: Hemorrhage is among the most serious complications of colorectal polypectomy and may occur after a longer postprocedure interval. OBJECTIVE: We aimed to elucidate the risk factors for delayed postpolypectomy hemorrhage, including both polyp characteristics and the general condition of the patients. DESIGN: Retrospective cohort study. PATIENTS: A total of 6617 cases of colorectal polypectomy was performed in 3138 consecutive patients in Japan. MAIN OUTCOME MEASUREMENTS: The risk factors for delayed postpolypectomy hemorrhage were assessed among polyp characteristics (form, size, histologic features) and the method of resection by unconditional logistic regression. Patient conditions (smoking, alcohol, hypertension, diabetes mellitus, hyperlipidemia) were compared between case-control pairs matched on polyp-related characteristics by conditional logistic regression. RESULTS: Hemorrhage occurred in 38 lesions (0.57%) of 37 patients (1.2%): 22 required endoscopic hemostasis and 1 required blood transfusion. Although polyp size was associated with the occurrence of delayed hemorrhage (10.0 +/- 6.9 mm in hemorrhage cases vs 5.6 +/- 3.8 mm in others, P < .0001), other polyp-related factors were not significant. Hypertension was a complication in 25 of 37 (68%) cases and in 21 of 74 (28%) matched controls, showing an adjusted odds ratio of 5.6 (95% CI 1.8-17.2, P = .001). Other patient characteristics were not significant. The interval between polypectomy and hemorrhage was significantly longer in patients with hypertension (median 6 days, range 2-14 days) than in those without hypertension (2.5 days, 1-9 days; P = .019). LIMITATIONS: This study does not provide information regarding prevention of hemorrhage. CONCLUSIONS: Hypertension is a significant risk factor for delayed colorectal postpolypectomy hemorrhage. The interval between polypectomy and hemorrhage can be as long as 14 days in the presence of hypertension.